FY11Seminar-StateBook-qxd by heku


									State of Illinois
Department of Central Management Services
Bureau of Benefits

   Benefit Choice
   Options Period
             Enrollment Period May 1 - May 31, 2010

                    State of Illinois
                    Effective July 1, 2010 - June 30, 2011
Plan Administrators
Who to call for information
    Plan Administrator             Toll-Free            TDD/TTY Number              Website Address
                              Telephone Number
 Health Alliance HMO            (800) 851-3379            (217) 337-8137          www.healthalliance.org
 Health Alliance Illinois       (800) 851-3379            (217) 337-8137          www.healthalliance.org
 HealthLink OAP                 (800) 624-2356            (800) 624-2356           www.healthlink.com
                                                             ext. 6280
 HMO Illinois                   (800) 868-9520            (800) 888-7114        www.bcbsil.com/stateofillinois
 Humana Health Plan             (866) 427-7478            (800) 833-3301        http://stateofil.humana.com
 Humana-Winnebago               (866) 427-7478            (800) 833-3301        http://stateofil.humana.com
 PersonalCare                   (800) 431-1211            (217) 366-5551          www.personalcare.org

     Plan Component            Administrator’s          Customer Service            Website Address
                              Name and Address           Phone Numbers
        Vision Plan          Out-of-Network Claims        (866) 723-0512           www.eyemedvision
                                 P.O. Box 8504       (800) 526-0844 (TDD/TTY)        care.com/stil
                                  Mason, OH
       Quality Care              CompBenefits
        Dental Plan            Group Number 950           (800) 999-1669         www.compbenefits.com
         (QCDP)                  P.O. Box 14285      (312) 829-1298 (TDD/TTY)
       Administrator        Lexington, KY 40512-4285
                                 Minnesota Life
      Life Insurance          Insurance Company           (888) 202-5525
            Plan              1 N Old State Capitol, (800) 526-0844 (TDD/TTY)     www.lifebenefits.com
                                    Suite 305
                               Springfield, IL 62701
      Long-Term Care                                      (800) 438-6388
           (LTC)                     MetLife         (800) 638-1004 (TDD/TTY)
     Flexible Spending
      Accounts (FSA)           Fringe Benefits
          Program           Management Company      (800) 342-8017
                                P.O. Box 1810  (800) 955-8771 (TDD/TTY)            www.myfBMC.com
        Commuter               Tallahassee, fL   (850) 514-5817 (fax)
     Savings Program             32302-1810    (866) 440-7152 (toll-free fax)
   Health/Dental Plans,
    Medicare COB Unit,
    FSA and CSP Unit,            CMS Group              (217) 782-2548
  Premium Collection Unit,   Insurance Division         (800) 442-1300          www.benefitschoice.il.gov
      Life Insurance,      201 East Madison Street (800) 526-0844 (TDD/TTY)
     Adoption Benefit          P.O. Box 19208
       and Smoking              Springfield, IL
     Cessation Benefit           62794-9208
Plan Administrator information continued on inside back cover.
               Table of Contents
Message to Plan Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Important Changes for Plan Year 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Member Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Member and Dependent Monthly Contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Health Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
           Important Reminders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
           Behavioral Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Managed Care Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
           Important Reminders about Managed Care Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
           Managed Care Plans in Illinois Counties (Map) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
           HMO Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
           Open Access Plan (OAP) Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
The Quality Care Health Plan (QCHP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Plan Participants Eligible for Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Prescription Drug Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
           QCHP Health Alliance Illinois, HealthLink OAP and Humana-Winnebago
                Prescription Drug Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
           Prescription Drug Benefit Co-pays and Deductibles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Vision Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Dental Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Life Insurance Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Flexible Spending Accounts (FSA) Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
           Medical Care Assistance Plan (MCAP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
           Dependent Care Assistance Plan (DCAP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Commuter Savings Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
           Parking Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
           Transit Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Optional Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Opt Out and Annuitant Waiver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Benefit Choice Options Period Election Form and Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Plan Administrators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inside Front and Back Covers

                                                                                  1                                     www.benefitschoice.il.gov
                                      Message to Plan
                                       The Benefit Choice Options Period will be held May 1, 2010
                                       through May 31, 2010, for all members. Members include
                                       employees (full-time employees, part-time employees working
                                       50% or greater and employees on leave of absence), annuitants,
                                       survivors and COBRA participants. Elections will be effective
                                       July 1, 2010.

Unless otherwise indicated, all Benefit Choice          • Elect to opt out (full-time employees, annuitants
changes should be made on the Benefit Choice              and survivors only). The election to opt out
Election Form. Members should complete the                will terminate the health, dental, vision and
form only if changes are being made. Your                 prescription coverage for the member and any
agency/university Group Insurance Representative          covered dependents (see page 26).
(GIR) will process the changes based upon the             Note: Members must provide proof of
information indicated on the form. Members                other comprehensive health coverage.
may obtain GIR names and locations by either
contacting the agency’s personnel office or             • Elect to waive health, dental, vision and
viewing the GIR listing on the Benefits website           prescription coverage (part-time employees
located at www.benefitschoice.il.gov.                     50% or greater, annuitants and survivors
                                                          required to pay a portion of premiums).
Members may make the following changes during
the Benefit Choice Options Period:                      • Re-enroll in the Program if previously opted out
                                                          (full-time employees, survivors or annuitants).
 • Change health plans.                                   Members have the option of not electing dental
                                                          coverage upon re-enrollment.
 • Add or drop dental coverage.
                                                        • Re-enroll in the Program if previously waived
 • Add or drop dependent coverage, including              (part-time employees 50% or greater, annuitants
   sponsored adult children and veteran adult             and survivors required to pay a portion of the
   children.                                              premium). Members have the option of not
                                                          electing dental coverage upon re-enrollment.
 • Increase or decrease member Optional Life
   insurance coverage.                                  • Re-enroll in the Program if coverage is
                                                          currently terminated due to non-payment of
 • Add or drop Child Life, Spouse Life and/or             premium while on leave of absence (employees
   AD&D insurance coverage.                               only – subject to eligibility criteria). Any
                                                          outstanding premiums plus the July premium
 • Enroll an unrelated same-sex Domestic                  must be paid before coverage will be
   Partner, including those previously terminated         reinstated. Note: Survivors and annuitants
   for non-payment of premium (Domestic                   are not eligible to re-enroll if previously
   Partner Enrollment Packet available online at          terminated for non-payment of premium.
                                                        • Enroll in MCAP and/or DCAP. Employees must
                                                          enroll each year; previous enrollment in the
                                                          program does not continue into the new plan

Important Changes
for Plan Year 2011
(Enrollment Period May 1 – May 31, 2010)
The information below represents changes to the State of
Illinois benefit plans. Please carefully review all the information
in this booklet to be aware of the benefit changes. The
Benefit Choice Options Period is May 1 - May 31, 2010. All
elections will be effective July 1, 2010.

Quality Care Dental Plan (QCDP)                             Flexible Spending Accounts Program
 • Dental annual plan year maximum benefit                  In accordance with the Patient Protection and
   increases to $2,500                                      Affordable Care Act, over-the-counter medicines and
 • Orthodontia lifetime maximum benefit increases           drugs purchased without a physician’s prescription
   to $2,000                                                will not be eligible for reimbursement through
                                                            the Medical Care Assistance Program (MCAP)
Vision Plan (see page 19 for detail)                        beginning January 1, 2011.
  • In and out-of-network benefit for contact
    lenses and standard frames increases                    Behavioral health benefits have been adjusted.
  • Out-of-network benefit for single, bifocal and          See page 7 for details.
    trifocal lenses increases

Member Responsibilities
You must notify the Group Insurance                           be effective the date of the written request if
Representative (GIR) at your employing agency,                made within 60 days of beginning the leave.
university or retirement system if:                           You will be billed by CMS for the cost of your
                                                              current coverage. Failure to pay the bill may
• You and/or your dependents experience a                     result in a loss of coverage and/or the filing of
  change of address.                                          an involuntary withholding order through the
• Your dependent loses eligibility. Dependents                Office of the Comptroller.
  that are no longer eligible under the Program             • You experience a change in Medicare status. A
  (including divorced spouses) must be reported               copy of the Medicare card must be provided to
  to your GIR immediately. Failure to report an               your GIR when a change in your or your
  ineligible dependent is considered a fraudulent             dependent's Medicare status occurs. Failure to
  act. Any premium payments you make on                       notify the Medicare Coordination of Benefits
  behalf of the ineligible dependent which result             Unit at Central Management Services of your
  in an overpayment will not be refunded.                     Medicare eligibility may result in substantial
  Additionally, the ineligible dependent may lose             financial liabilities.
  any rights to COBRA continuation coverage.
                                                            • You get married or divorced.
• You go on a Leave of Absence or have time
  away from work. When you go on a Leave of                 • You have a baby or adopt a child.
  Absence and are not receiving a paycheck or are
  ineligible for payroll deductions, you are still          • Your spouse's or dependent’s employment
  responsible to pay for your Group Insurance                 status changes.
  coverage. You should immediately contact your             Contact your GIR if you are uncertain whether or
  GIR for your options, if any, to make changes to          not a life-changing event needs to be reported.
  your current coverage. Requested changes will
                                                        3                         www.benefitschoice.il.gov
          Member and Dependent
          Monthly Contributions
While the State covers most of the cost of employee health coverage, employees must also make a
monthly salary-based contribution. The salary-based contributions indicated below will begin July 1,
2010, and remain in effect until June 30, 2011. Employees who retire, accept a voluntary salary reduction
or return to State employment at a different salary may have their monthly contribution adjusted based
upon the new salary (this applies to employees who return to work after having a 10-day or greater
break in State service after terminating employment – this does not apply to employees who have a
break in coverage due to a leave of absence).
 Employee Annual Salary               Employee Monthly Health Plan Contributions*
  $29,800 & below                     Managed Care: $47.00           Quality Care:                 $72.00
  $29,801 - $45,000                   Managed Care: $52.00           Quality Care:                 $77.00
  $45,001 - $59,900                   Managed Care: $54.50           Quality Care:                 $79.50
  $59,901 - $74,900                   Managed Care: $57.00           Quality Care:                 $82.00
  $74,901 & above                     Managed Care: $59.50           Quality Care:                 $84.50
Note: Employees who reside in Illinois but do not have access to a managed care plan may be eligible
for a lower health plan contribution. Contact the CMS Group Insurance Division, Analysis and
Resolution Unit at (800) 442-1300 or (217) 558-4671, for assistance.

              Retiree, Annuitant and Survivor Monthly Health Plan Contribution
    20 years or more of creditable service                       $0.00
    Less than 20 years of creditable service and,                Required to pay a
         • SERS/SURS annuitant/survivor on or after 1/1/98,      percentage of the cost
           or                                                    of the basic coverage.
         • TRS annuitant/survivor on or after 7/1/99
                 Call the appropriate retirement system for applicable premiums.
             SERS: (217) 785-7444; SURS: (800) 275-7877; TRS: (800) 877-7896

Monthly Optional Term Life Plan Contributions
   Member by Age               Monthly Rate
                                Per $1,000                       AD&D Monthly Rate Per $1,000
   Under 30                      $0.06                    Accidental Death
   Ages 30 - 34                   0.08                    & Dismemberment                          0.02
   Ages 35 - 44                   0.10
   Ages 45 - 49                   0.16
                                                                     Spouse Life Monthly Rate
   Ages 50 - 54                   0.24
   Ages 55 - 59                   0.44                   Spouse Life $10,000 coverage
   Ages 60 - 64                   0.66                   (Employees and Annuitants under age 60)    6.94
   Ages 65 - 69                   1.38                   Spouse Life $5,000 coverage
   Ages 70 - 74                   2.52                   (Annuitants age 60 and older)              3.47
   Ages 75 - 79                   3.52
   Ages 80 - 84                   4.20
   Ages 85 - 89                   5.20                                  Child Life Monthly Rate
   Ages 90 and above              6.50                   Child Life $10,000 coverage                0.52
             Member and Dependent
             Monthly Contributions
The monthly dependent contribution is in addition to the member health plan contribution. Dependents
will be enrolled in the same plan as the member. The Medicare dependent contribution applies only if
Medicare is PRIMARY for both Parts A and B. Members with questions regarding Medicare status may
contact the CMS Group Insurance Division, Medicare Coordination of Benefits (COB) Unit at (800) 442-1300
or (217) 782-7007.
                               Dependent Monthly Health Plan Contributions*
                                                                                   One            Two or more
         Health Plan Name                  One             Two or more           Medicare          Medicare
            and Code                    Dependent          Dependents            A and B            A and B
                                                                                 Primary            Primary
                                                                                Dependent         Dependents
 HMO Illinois
 (Code: BY)                                 $ 83                $116               $ 79              $116
 (Code: AS)                                 $ 92                $130               $ 88              $130
 Humana Health Plan
 (Code: CA)                                 $ 92                $130               $ 89              $130
 Health Alliance HMO
 (Code: AH)                                 $ 94                $133               $ 89              $133
 Health Alliance Illinois
 (Code: BS)                                 $103                $145               $100              $145
 HealthLink OAP
 (Code: Cf)                                 $105                $149               $102              $149
 (Code: CE)                                 $107                $152               $104              $152
 Quality Care Health Plan
 (Code: D3)                                 $196                $226               $142              $203

         Member Monthly Quality Care                       Contribution Calculation Worksheet
       Dental Plan (QCDP) Contributions*                   Member Monthly Health Contribution:       $_______
                                                           (see chart on page 4)
   Member Only                         $11.00
                                                           Dependent Monthly Health Contribution: $_______
   Member plus                                             (if insuring dependents, see chart above)
   1 Dependent                         $17.00
                                                           Monthly Dental Contribution:              $_______
   Member plus                                             (see chart to left)
   2 or more Dependents                $19.50              Monthly Optional Term Life Contribution:$_______
                                                           (see chart on page 4)
                                                           My Total Monthly Contribution:            $_______
                                                           Note: An interactive Premium Calculation Worksheet is
                                                           available for full-time employees online at www.bene-
* Part-time employees are required to pay a
  percentage of the State’s portion of the contribution.

                                                           5                        www.benefitschoice.il.gov
           Health Plan
The State of Illinois offers its employees and              Electing to opt out includes the termination of health,
annuitants health benefits through the State                dental, vision, behavioral health and prescription
Employees Group Insurance Program. Prescription,            coverage. See page 26 for details. If you do not
behavioral health and vision coverage are included          have other comprehensive health coverage, you
at no additional cost when enrolled in health               must enroll in the State’s health plan.
coverage. With limited exceptions, the State makes
monthly contributions toward your health premiums.          If you change health plans during the Benefit
Active employees and annuitants should refer to             Choice Period, or elect health coverage after opting
pages 4-5 for the monthly contribution amounts.             out, your new health insurance ID cards will be
                                                            mailed to you directly from your health insurance
As an employee or annuitant of the State, you are           carrier, not from the Department of Central
offered a number of health insurance coverage               Management Services. You should expect your
plans:                                                      new ID cards by the beginning of the plan year,
  • Health Maintenance Organization (HMOs)                  July 1, 2010. If you need to have services provided
                                                            on or after July 1, 2010, but have not yet received
  • Open Access Plan (OAP)                                  your ID cards, contact your health insurance carrier.
  • Quality Care Health Plan (QCHP) – a plan with
    both in-network and out-of-network benefits             Remember, whatever health plan you elect during
                                                            the Benefit Choice Period will remain in effect the
The health insurance plans differ in the benefit            entire plan year, unless you experience a qualifying
levels they provide, the doctors and hospitals you          change in status that allows you to change plans.
can access and the cost to you. See pages 8-13
for information to help you determine which plan            Most expenses that you or your dependent incur
is right for you.                                           outside what your elected health plan covers, such
                                                            as co-payments and deductibles, are reimbursable
You also have the option of opting out of health            through the pre-tax Medical Care Assistance Plan
coverage if you have other comprehensive                    (MCAP). See the Flexible Spending Accounts
health coverage provided by an entity other than            section on page 22 for details.
the Department of Central Management Services.

Important Reminders
Continuity of Care After Health Plan Change:                Beneficiary Designations: You should periodically
Members who change health plans and are then                review all beneficiary designations and make the
hospitalized prior to July 1 and are discharged on          appropriate updates. Remember, you may have
or after July 1, or have dependents that are                death benefits through various state-sponsored
hospitalized, should contact both the current and           programs, each having a separate Beneficiary
future health plan administrators and Primary               form:
Care Physicians as soon as possible to coordinate
the transition of services.                                    • State of Illinois life insurance
                                                               • Retirement benefits
Members or dependents involved in an ongoing
course of treatment or who have entered the third              • Deferred Compensation
trimester of pregnancy should contact the new
plan to coordinate the transition of services for           Documentation Requirements
treatment.                                                  • Documentation is required when adding
                                                              dependent coverage.
COBRA Participants: During the Benefit Choice
Period, COBRA participants have the same benefit            • An approved Statement of Health is required to
options available to them as all other members                add or increase member Optional Life coverage
with the exception of life insurance coverage,                or to add Spouse Life or Child Life coverage.
which is not available to COBRA participants.               • If opting out, proof of other comprehensive
COBRA health and dental rates for the 2011 plan               health coverage provided by an entity other than
year (July 1, 2010 – June 30, 2011) will be available         the Department of Central Management Services
on or after May 1, 2010, by calling 217-558-6194.             is required.
Behavioral Health Services
The coverage of behavioral health services (mental
health and substance abuse) under the benefit plan is
being adjusted for the FY 2011 plan year to comply
with the federal Mental Health Parity and Addiction
Equity Act of 2008. The federal law requires health
plans to cover behavioral health services at levels
equal to those of the plan’s medical benefits.

Quality Care Health Plan:                                   Managed Care Plans:
Behavioral health services will now be included in          Behavioral health services will continue to be
an enrollee’s annual plan deductible and annual             provided under the managed care plans; however,
out-of-pocket maximum. Behavioral health services           restrictions on the number of allowable visits and
will no longer be subject to separate co-payments,          hospital days will be eliminated. Covered services
limits or other specific provisions. Instead, covered       for behavioral health must still meet the managed
services for behavioral health which meet the plan          care plan administrator’s medical necessity criteria
administrator’s medical necessity criteria will be          and will be paid in accordance with the managed
paid in accordance with the Quality Care Health             care benefit schedules on pages 10 and 11. Please
Plan benefit schedule on pages 12 and 13 for                contact the managed care plan for specific benefit
in-network and out-of-network providers.                    information.
Magellan Behavioral Health continues to be the
plan administrator for behavioral health services
under the Quality Care Health Plan. Please
contact Magellan for specific benefit information.

Disease Management Programs
and Wellness Offerings
Disease Management Programs:                                Wellness Offerings:
Disease Management Programs are utilized by                 Wellness options and preventive measures are
CIGNA and the managed care health plans as a                offered and encouraged by CIGNA and the
way to improve the health of plan participants.             managed care plans. Offerings range from health
You may be contacted by your health plan to                 risk assessments to educational materials and, in
participate in these programs.                              some cases, discounts on items such as gym
                                                            memberships and weight loss programs. These
                                                            offerings are available to plan participants and
                                                            are provided to help you take control of your
                                                            personal health and well-being. Information
                                                            about the various offerings is available on the
                                                            plan administrators’ websites listed on the inside
                                                            covers of this book and on the Benefits website.

                                                        7                         www.benefitschoice.il.gov
Managed Care Plans
There are 7 managed care plans available based on geographic
location. All offer comprehensive benefit coverage. Distinct
advantages to selecting a managed care health plan include
lower out-of-pocket costs and virtually no paperwork. Managed
care plans have limitations including geographic availability and
defined provider networks.

Health Maintenance Organizations (HMOs)                    Open Access Plan (OAP)
Members must select a Primary Care Physician               The OAP, administered by HealthLink, provides
(PCP) from a network of participating providers.           three benefit levels broken into tier groups. Tier I
The PCP directs healthcare services and must               and Tier II require the use of network providers
make referrals for specialists and hospitalizations.       and offer benefits with co-payments and/or
When care and services are coordinated through             coinsurance. Tier III (out-of-network) offers
the PCP, only a co-payment applies. No annual              members flexibility in selecting healthcare
plan deductibles apply for medical services;               providers, but requires higher out-of-pocket costs.
however, there is an annual $50 prescription               A deductible applies for medical services under
deductible applied for each plan participant. The          Tier II and Tier III. Regardless of the tier used, an
minimum level of HMO coverage provided by all              annual $50 prescription deductible will be applied
plans is described on page 10. Please note that            to each plan participant for prescription coverage.
some HMOs provide additional coverage, over                It is important to remember that the level of
and above the minimum requirements.                        benefits is determined by the healthcare provider
                                                           selected. Members enrolled in the OAP can mix
                                                           and match providers. Specific benefit levels
                                                           provided under each tier are described on page 11.

Important Reminders About Managed Care Plans
Primary Care Physician (PCP) Leaves the Network:           Dependents: Eligible dependents that live apart
If a member’s PCP leaves the managed care plan’s           from the member’s residence for any part of a plan
network, the member has three options:                     year may be subject to limited service coverage. It
  • Choose another PCP within that plan;                   is critical that members who have an out-of-area
                                                           dependent (such as a college student) contact the
  • Change managed care plans; or                          managed care plan to understand the plan’s
  • Enroll in the Quality Care Health Plan.                guidelines on this type of coverage.

The opportunity to change plans applies only to            Plan Year Limitations: Managed care plans may
PCPs leaving the network and does not apply to             impose benefit limitations based on a calendar
specialists or women’s health care providers who           year schedule. In certain situations, the State’s
are not designated as the PCP .                            plan year may not coincide with the managed
                                                           care plan’s year.
Provider Network Changes: Managed care plan
provider networks are subject to change. Members           Behavioral Health Services: Behavioral health
should always call the respective plan to verify           services are for the diagnosis and treatment of
participation of specific providers, even if the           mental health and/or substance abuse disorders
information is printed in the plan’s directory.            and are available through the member’s health plan.

Managed Care                                               Jo Daviess Stephenson Winnebago Boone Mc Henry
                                                               AS          AH AS          AS BY AS AS BY

   Plans in
                                                                           BY                CE                CA
                                                                     Carroll          Ogle
                                                                                                    De Kalb Kane            Cook
                                                                    AH AS          AH AS BY

Illinois Counties                                                                                     BS
                                                                                                               BY Du Page
                                                                   Whiteside                                                     BY
                                                                                        Lee           BY                BY
                                                                    AH AS             AH AS           CA Kendall
                                                          AS                                                  AH BY Will
                                                    AH                          Bureau           La Salle
                                                              Henry                                                     AS
                                           Rock Island        AH                AH AS              AH
                                                                                                   AS         Grundy BY
                                             Mercer           CA                                               AH
                                                                                        AH AS
                                           AH CA AS                       Stark      Putnam                    BY
                                                                      AH AS                                               Kankakee
                                                Warren      Knox      CA BY       AH AS CA                               AS BY CF

State Managed Care                               AH AH AS                 Peoria      Woodford            AH                 Iroquois
                                       AH        AS      CA CF AH AS                                      CA
Health Plans                           CA        CA
                                                                                      AH AS CA
                                                                                         CF BY
                                                                      BY CA                                                    AS
For Plan Year 2011                Hancock Mc Donough
                                                           Fulton         CF Tazewell            McLean           Ford         CF
                                   BS         AH          AH AS             AH AS BY            AH AS
                                                          BY CA               CA CF                            AH AS CF
                                   CA         CF                                                CA CF                         Vermilion
                                   CF                     CF        Mason
                                             Schuyler           AH BY CF Logan                 De Witt              AH           AH
                                 Adams          BS CF AS Menard AH BY AH CF BY Piatt          CA
                                                                                                                    AS           AS
                                 AS BS     BS CF         Cass       AH BY         CF AS                  AH         CF           CF
                                  CF       Brown BS CF BY CF AS                                AS        AS
                                                                         Sangamon              BS        CF      Douglas
                                                        Morgan                                                                  Edgar
                                        Pike      Scott                AH AS                   CF Moultrie AH AS CF
                                                   BS     AH AS                                                               AS BS
                                       AS BS CF BY BY CF BY CF Christian                              AH AS
                                                                                                                  Coles          CF
                                          CF                                                               CF
                                                     Greene                         AH AS                      AH AS CF
                                                   AS BS Macoupin                   BY CF                                     Clark

                                                                                                AH AS CF Cumberland            AS
                                                   CF BY        AS BS        Montgomery
The key below indicates the                                                                                    AH AS CF BS CF
                                                                BY CF AH CF
two-letter carrier codes for                         Jersey                   BY AS        Fayette Effingham Jasper
                                              AS AS BS CF                                              AH AS
HMO and OAP plans. Plans                                                         Bond         AH                     AH Crawford
                                                                Madison                                   CF       CF AS BS CF
are available in the counties                                                   AS CF      CF AS
where their code appears.                                       AH AS             BY                        Clay Richland Lawrence
                                                                BY CF           Clinton        Marion BS CF
                                                                                                                     BS CF BS CF
                                                                                AS CF         AS BS
                                                               St. Clair                        CF
                                                                                BY                          Wayne            Wabash
                                                               AH AS                                                     BS BS
Carrier Codes:                                           AS BY CF
                                                                             Washington Jefferson
                                                                            AH AS CF          AS BS           CF         CF
                                                         BY CF                                  CF      Hamilton White
AH – Health Alliance HMO                                           Randolph       Perry
                                                                                                           BS       BS
AS – PersonalCare                                                  AH BY AH CF Franklin
                                                                                              AH CF        CF       CF
BS – Health Alliance Illinois                                            CF
                                                                                Jackson                  Saline Gallatin
BY – HMO Illinois                                                                AH CF Williamson AH AH
CA – Humana Health Plan                                                                       AH CF        CF      CF
CE – Humana-Winnebago                                                                Union Johnson Pope AH CF   Hardin
CF – HealthLink Open Access                                                         AH CF AH CF BS
                                                                                     BS Pulaski
Note: QCHP available Statewide                                                                    Massac

                                                                                     CF     BS        BS CF


                                                                   9                             www.benefitschoice.il.gov
           HMO Benefits
The HMO coverage described below represents the
minimum level of coverage an HMO is required to
provide. Benefits are outlined in each plan’s Summary
Plan Document (SPD). It is the member’s responsibility
to know and follow the specific requirements of the
HMO plan selected. Contact the plan for a copy of the
SPD. A $50 prescription deductible applies to each
plan participant (see page 18 for details).

                                           HMO Plan Design
 Plan year maximum benefit                             Unlimited
 Lifetime maximum benefit                              Unlimited
                                           Hospital Services
 Inpatient hospitalization                             100%   after   $275   co-payment per admission
 Alcohol and substance abuse                           100%   after   $275   co-payment per admission
 Psychiatric admission                                 100%   after   $275   co-payment per admission
 Outpatient surgery                                    100%   after   $175   co-payment
 Diagnostic lab and x-ray                              100%
 Emergency room hospital services                      100%   after $200 co-payment per visit
                                  Professional and Other Services
 Physician Office visit                                100% after $15 co-payment per visit
 (including physical exams and
 Specialist Office visit                               100% after $20 co-payment per visit
 Well Baby Care (first year of life)                   100%
 Outpatient Psychiatric and Substance Abuse            100% after $20 co-payment per visit
 Prescription drugs                                    $10 co-payment for generic
 ($50 deductible applies; formulary                    $24 co-payment for preferred brand
 is subject to change during plan year)                $48 co-payment for non-preferred brand
 Durable Medical Equipment                             80%
 Home Health Care                                      $20 co-payment per visit

Some HMOs may have benefit limitations on a calendar year.

Open Access Plan (OAP) Benefits
The benefits described below represent the minimum level of coverage available in the OAP. Benefits
are outlined in the plan’s Summary Plan Document (SPD). It is the member’s responsibility to know and
follow the specific requirements of the OAP plan. Contact HealthLink for a copy of the SPD. A $50
prescription deductible applies to each plan participant (see page 18 for details).

 Benefit                            Tier I                            Tier II                          Tier III (Out-of-Network)
                                    100% Benefit                      90% Benefit                      80% Benefit
 Plan Year Maximum Benefit          Unlimited                         Unlimited                        $1,000,000
 Lifetime Maximum Benefit           Unlimited                         Unlimited                        $1,000,000
 Annual Out-of-Pocket Max
 Per Individual Enrollee            Not Applicable                    $600                             $1,500
 Per family                                                           $1,200                           $3,500
 Annual Plan Deductible             $0                                $200 per enrollee*               $300 per enrollee*
 (must be satisfied for all
                                                          Hospital Services
 Inpatient                          100% after $275                   90% of network charges           80% of U&C after $425
                                    co-payment per admission          after $325 co-payment per        co-payment per admission
 Inpatient Psychiatric              100% after $275                   90% of network charges after     80% of U&C after $425
                                    co-payment per admission          $325 co-payment per admission    co-payment per admission
 Inpatient Alcohol and              100% after $275                   90% of network charges after     80% of U&C after $425
 Substance Abuse                    co-payment per admission          $325 co-payment per admission    co-payment per admission
 Emergency Room                     100% after $200 co-payment        90% of network charges           80% of U&C after lesser of
                                    per visit                         after $200 co-payment            $200 co-payment per visit,
                                                                      per visit                        or 50% of U&C
 Outpatient Surgery                 100% after $175 co-payment        90% of network charges           80% of U&C after $175
                                    per visit                         after $175 co-payment            co-payment
 Diagnostic Lab and X-ray           100%                              90% of network charges           80% of U&C
                                            Physician and Other Professional Services
 Physician Office Visits            100% after $15 co-payment         90% of network charges           80% of U&C
 Specialist Office Visits           100% after $20 co-payment         90% of network charges           80% of U&C
 Preventive Services,               100% after $15 co-payment         90% of network charges           Covered under Tier I and
 including immunizations,                                                                              Tier II only
 allergy testing and treatment
 Well Baby Care                     100%                              90% of network charges           Covered under Tier I and
 (first year of life)                                                                                  Tier II only
 Outpatient Psychiatric             100% after $20 co-payment         90% of network charges           80% of U&C
 and Substance Abuse
                                                           Other Services
                Prescription Drugs – Covered through State of Illinois administered plan, Medco; $50 deductible applies
                  Generic $10                     Preferred Brand $24                     Non-Preferred Brand $48
 Durable Medical Equipment          100%                              90% of network charges           80% of U&C
 Skilled Nursing facility           100%                              90% of network charges           Covered under Tier I and
                                                                                                       Tier II only
 Transplant Coverage                100%                              90% of network charges           Covered under Tier I and
                                                                                                       Tier II only
 Home Health Care                   100% after $20 co-payment         90% of network charges           Covered under Tier I and
                                                                                                       Tier II only

* An annual plan deductible must be met before plan benefits apply. Benefit limits are measured on a plan
  year. Plan co-payments, deductibles and amounts over usual and customary (U&C) do not count toward the
  out-of-pocket maximum.

                                                                 11                                   www.benefitschoice.il.gov
The Quality Care Health Plan (QCHP)
QCHP (administered by CIGNA) is the medical plan that offers a comprehensive range of benefits. Under
the QCHP, plan participants can choose any physician or hospital for medical services; however, plan
participants receive enhanced benefits, resulting in lower out-of-pocket costs, when receiving services
from a QCHP network provider.
The QCHP has a nationwide network (Open Access Plan (OAP)) that consists of physicians, hospitals and
ancillary providers. Notification to Intracorp, the QCHP notification administrator, is required for certain
medical services in order to avoid penalties. Contact Intracorp at (800) 962-0051 for direction. Note: The
QCHP and the HealthLink OAP are separate health plans with a separate plan design.
QCHP utilizes Magellan for behavioral health benefits and the Medco retail pharmacy network for prescription
benefits. A $75 prescription deductible applies to each plan participant (see page 18 for details).
Plan participants can access plan benefit and participating QCHP network information, Explanation of
Benefits (EOB) statements and other valuable health information online. To access website links to plan
administrators, visit the Benefits website at www.benefitschoice.il.gov.
                                         Plan Year Maximums and Deductibles
 Plan Year Maximum                                                  Unlimited
 Lifetime Maximum                                                   Unlimited
 Plan Year Deductible                                               The plan year deductible is based upon each
                                                                    employee’s annual salary (see chart below)
 Additional Deductibles*                                            Each emergency room visit          $400
 * These are in addition to the plan year deductible.               QCHP hospital admission            $50
                                                                    Non-QCHP hospital admission        $300
                                                                    Transplant deductible              $100

                                                    Plan Year Deductibles
      Employee’s Annual Salary                                    Member Plan              Family Plan Year
      (based on each employee’s                                  Year Deductible            Deductible Cap
      annual salary as of April 1st)
      $59,900 or less                                                $300                         $750
      $59,901 - $74,900                                              $400                         $1,000
      $74,901 and above                                              $450                         $1,125
      Retiree/Annuitant/Survivor                                     $300                         $750
      Dependents                                                     $300                         N/A

                                       Out-of-Pocket Maximums
Deductibles and eligible coinsurance payments accumulate toward the annual out-of-pocket maximum.
There are two separate out-of-pocket maximums: In-Network and Out-of-Network. Coinsurance and
deductibles apply to one or the other, but not both. After the out-of-pocket maximum has been met,
coinsurance amounts are no longer required and the plan pays 100% of eligible charges for the remainder
of the plan year.
                       In-Network:                                           Out-of-Network:
                   $1,200 per individual                                   $4,400 per individual
              $3,000 per family per plan year                         $8,800 per family per plan year
 The following do not apply toward out-of-pocket maximums:
   • Prescription Drug benefits, deductibles or co-payments.
   • Notification penalties.
   • Ineligible charges (amounts over Usual and Customary (U & C), charges for non-covered services and
     charges for services deemed not to be medically necessary).
   • The portion ($50) of the Medicare Part A deductible the plan participant is responsible to pay.
                    QCHP - Plan Benefits
                                            Hospital Services
 QCHP Hospital Network                                     • 90% after annual plan deductible.
                                                           • $50 deductible per hospital admission.
                                                           • $300 deductible per hospital admission.

                                                           • If the member resides in Illinois or within 25
                                                             miles of a QCHP hospital and the member
                                                             chooses to use a non-QCHP hospital and/or
                                                             voluntarily travels in excess of 25 miles when a
                                                             QCHP hospital is available within the same travel
                                                             distance, the plan pays 65% after the annual
 Non-QCHP Hospitals                                          plan deductible.

                                                           • If the member resides in Illinois and has no
                                                             QCHP hospital available within 25 miles and
                                                             voluntarily chooses to travel further than the
                                                             nearest QCHP hospital, the plan pays 65% after
                                                             the annual plan deductible.

                                                           • If the member does not reside in Illinois or within
                                                             25 miles of a QCHP hospital, the plan pays 80%
                                                             after the annual plan deductible.
                                           Outpatient Services
 Lab/X-ray                                                 90% of U&C after annual plan deductible.
 Approved Durable Medical Equipment (DME) and              80% of U&C after annual plan deductible.
 Licensed Ambulatory Surgical Treatment Centers            90% of negotiated fee or 80% of U&C, as
                                                           applicable, after plan deductible.
                                    Professional and Other Services
 Provider Services included in the QCHP Network            90% of negotiated fee after the annual plan
                                                           deductible. U&C charges do not apply.
 Provider Services not included in the QCHP Network        70% of U&C after the annual plan deductible for
                                                           inpatient, outpatient and office visits.
 Chiropractic Services – medical necessity required        90% of negotiated fee or 80% of U&C, as applicable,
 (up to a maximum of 30 visits per plan year)              after plan deductible.
                                           Transplant Services
 Organ and Tissue Transplants                              80% of negotiated fee after $100 transplant
                                                           deductible. Benefits are not available unless
                                                           approved by the Notification Administrator,
                                                           Intracorp. To assure coverage, the transplant can-
                                                           didate must contact Intracorp prior to beginning
                                                           evaluation services.

Network providers are subject to change throughout the plan year. Always call the respective plan
administrator to verify participation of a specific provider.

                                                      13                           www.benefitschoice.il.gov
Plan Participants (Members and Dependents)
   Eligible for Medicare
What is Medicare?                                              State of Illinois
Medicare is a federal health insurance program
                                                               Medicare Requirements
for the following:                                             Each plan participant must contact the SSA and
  • Participants age 65 or older                               apply for Medicare benefits upon turning the age of
  • Participants under age 65 with certain disabilities        65. If the SSA determines that a plan participant is
  • Participants of any age with End-Stage Renal               eligible for Medicare Part A at a premium-free
    Disease (ESRD)                                             rate, the plan participant must accept the
                                                               Medicare Part A coverage.
Medicare has the following parts to help cover
specific services:                                             If the SSA determines that a plan participant is
  • Medicare Part A (Hospital Insurance): Part A               not eligible for premium-free Medicare Part A
    coverage is a premium-free program for                     based on his/her own work history or the work
    participants with enough earned credits based              history of a spouse at least 62 years of age (when
    on their own work history or that of a spouse              applicable), the plan participant must request a
    at least 62 years of age (when applicable) as              written statement of the Medicare ineligibility
    determined by the Social Security                          from the SSA. Upon receipt, the written statement
    Administration (SSA).                                      must be forwarded to the Medicare COB Unit to
  • Medicare Part B (Outpatient and Medical                    avoid a financial penalty. Plan participants who
    Insurance): Part B coverage requires a monthly             are ineligible for premium-free Medicare Part A
    premium contribution. With limited exception,              benefits, as determined by the SSA are not
    enrollment is required for members who are                 required to enroll into Medicare Parts A or B.
    retired or who have lost Current Employment
    Status and are eligible for Medicare.
  • Medicare Part D (Prescription Drug Insurance):             Employees with Current
    Part D coverage is not required for plan
    participants in the State Employees Group
                                                               Employment Status
    Insurance Program. Medicare Part D coverage                (and their applicable
    requires a monthly premium, unless the
    participant qualifies for extra-help assistance.
                                                               Members who are actively working for the State
In order to apply for Medicare benefits, plan                  of Illinois and become eligible for Medicare (or have
participants are instructed to contact their local             a dependent that becomes eligible for Medicare)
SSA office or call 1-800-772-1213. Plan participants           due to turning age 65 or due to a disability (under
may also contact the SSA via the internet at                   the age of 65) must accept the premium-free
www.socialsecurity.gov to sign up for Medicare                 Medicare Part A coverage, but may delay the
Part A.                                                        purchase of Medicare Part B coverage. The State
                                                               group insurance program will remain the primary
To ensure that benefits are coordinated appropriately          insurance for plan participants eligible for Medicare
and to prevent financial liabilities with healthcare           due to age or disability until the date the member
claims, plan participants must notify the State of             retires or loses Current Employment Status (such
Illinois CMS Medicare COB Unit when they                       as no longer working due to a disability-related
become eligible for Medicare. The Medicare COB                 leave of absence). Upon such an event, Medicare
Unit can be reached by calling 1-800-442-1300 or               Part B is required by the State.

Plan Participants (Members and Dependents)
  Eligible for Medicare (cont.)
Retirees and Employees without
Current Employment Status
(and their applicable
Members who are retired or who have lost Current
Employment Status (such as no longer working
due to a disability related leave of absence) and
are eligible for Medicare (or have a dependent
that becomes eligible for Medicare) due to turning
age 65 or due to a disability (under the age of 65)
must enroll in the Medicare Program. Medicare is
the primary payer for health insurance claims
over the State group insurance program. Failure
to enroll and maintain enrollment in Medicare
Parts A and B when Medicare is the primary
insurance payer will result in a reduction of benefits
under the State group insurance plan and will
result in additional out-of-pocket expenditures for
health-related claims.

Survivors (and their applicable                               Plan Participants Eligible for
Dependents)                                                   Medicare on the Basis of End
Survivors (or their dependents) who become                    Stage Renal Disease (ESRD):
eligible for Medicare due to turning age 65 or due
to a disability (under the age of 65) must enroll in          Plan participants who are eligible for Medicare
the Medicare Program. Medicare is the primary                 benefits based on End Stage Renal Disease
payer for health insurance claims over the State              (ESRD) must contact the State of Illinois CMS
group insurance program. Failure to enroll and                Medicare COB Unit for information regarding
maintain enrollment in Medicare Parts A and B                 Medicare requirements and to ensure proper
when Medicare is the primary insurance payer                  calculation of the 30-month Coordination of
will result in a reduction of benefits under the              Benefit Period.
State group insurance plan and will result in
additional out-of-pocket expenditures for
health-related claims.                                        Each plan participant who becomes eligible for
                                                              Medicare is required to submit a copy of his or
If you are a survivor enrolled in Medicare Part A             her Medicare card to his or her Group Insurance
only, it is imperative that you contact the                   Representative (GIR).
Medicare COB Unit to discuss the Medicare

                                                         15                        www.benefitschoice.il.gov
              Prescription Drug Benefit
Plan participants enrolled in any State health plan have prescription drug benefits
included in the coverage. All prescription medications are compiled on a preferred
drug list (“formulary list”) maintained by each health plan's Prescription
Benefit Manager (PBM). Each plan maintains a formulary list of medications.
These formulary lists are subject to change any time during the plan year.
To compare formulary lists, cost-savings programs and to obtain a list of
network pharmacies that participate in the various health plans, plan participants
should visit the website of each health plan. Certain health plans notify plan
participants by mail when a prescribed medication they are currently taking is
reclassified into a different formulary list category. If a formulary change
occurs, plan participants should consult with their physician to determine if a
change in prescription is appropriate. Regardless of plan chosen, a prescription deductible applies to
each plan participant each plan year (see page 18).

Plan participants who have additional prescription drug coverage, including Medicare, should contact
their healthcare plan for Coordination of Benefits (COB) information.

Health Alliance HMO, HMO Illinois, Humana                      Health Alliance Illinois, HealthLink OAP,
Health Plan and PersonalCare all use a separate                Humana-Winnebago and the Quality Care Health
Prescription Benefit Manager (PBM) to administer               Plan (QCHP) have prescription drug benefits
their prescription drug benefits. Members who                  administered through the Prescription Benefit
elect one of these plans must utilize a pharmacy               Manager (PBM), Medco. Prescription drug benefits
participating in the plan’s pharmacy network or                are independent of other medical services and are
the full retail cost of the medication will be charged.        not subject to the medical plan year deductible or
Partial reimbursement may be provided if the plan              out-of-pocket maximums. In order to receive the
participant files a paper claim with the health plan.          best value, plan participants enrolled in one of
It should be noted that most plans do not cover                these plans should carefully review the various
over-the-counter drugs or drugs prescribed by a                prescription networks outlined on page 17. Most
medical professional, including dentists, other                drugs purchased with a prescription from a
than the plan participant’s primary care physician,            physician or a dentist are covered; however,
even if purchased with a prescription. Members                 over-the-counter drugs are not covered, even if
should direct prescription benefit questions to the            purchased with a prescription. If a plan participant
respective health plan administrator.                          elects a brand name drug and a generic is available,
                                                               the plan participant must pay the cost difference
                                                               between the brand product and the generic product,
                                                               in addition to the generic co-payment.

                                                                                ≈   Medco: (800) 899-2587
                                                                                    Website: www.medco.com

   QCHP, Health Alliance Illinois, HealthLink OAP
 and Humana-Winnebago Prescription Drug Benefit
                                 Non-Maintenance Medication
In-Network Pharmacy - Retail pharmacies that                     Out-of-Network Pharmacy - Pharmacies that do
contract with Medco and accept the co-payment                    not contract with Medco are referred to as out-of-
amount for medications are referred to as in-network             network pharmacies. In most cases, prescription
pharmacies. Plan participants who use an in-                     drug costs will be higher when an out-of-network
network pharmacy must present their Medco ID                     pharmacy is used. If a medication is purchased at
card/number or they will be required to pay the full             an out-of-network pharmacy, the plan participant
retail cost. If, for any reason, the pharmacy is not             must pay the full retail cost at the time the
able to verify eligibility (submit claim electronically),        medication is dispensed. Reimbursement of
the plan participant must submit a paper claim to                eligible charges may be obtained by submitting a
Medco. The maximum supply of non-maintenance                     paper claim and the original prescription receipt
medication allowed at one fill is 60 days, although              to Medco. Reimbursement will be provided at the
two co-payments will be charged for any prescription             applicable brand or generic in-network price
that exceeds a 30-day supply. A list of in-network               minus the appropriate in-network co-payment.
pharmacies, as well as claim forms, are available                Claim forms are available by visiting the Benefits
on the Benefits website.                                         website.

                                      Maintenance Medication
The Maintenance Medication Program (MMP) was                     participant uses an in-network pharmacy not part of
developed to provide an enhanced benefit to plan                 the Maintenance Network, only the first two 30-day
participants who use maintenance medications.                    fills will be covered at the regular co-payment
Maintenance medication is medication that is taken               amount. Subsequent fills will be charged double
on a regular basis for conditions such as high blood             the co-payment rate.
pressure and high cholesterol. To determine
whether a medication is considered a maintenance                 The Mail Order Pharmacy provides participants the
medication, contact a Maintenance Network                        opportunity to receive medications directly from
pharmacist or contact Medco. A list of pharmacies                Medco. Both maintenance and non-maintenance
participating in the Maintenance Network is available            medications may be obtained through the mail
at www.benefitschoice.il.gov. When plan participants             order process.
use either the Maintenance Network or the Mail                   To utilize the Mail Order Pharmacy, plan participants
Order Pharmacy for maintenance medications,                      must submit an original prescription from the
they will receive a 90-day supply of medication                  attending physician. For maintenance medication,
(equivalent to 3 fills) for only two co-payments.                the prescription should be written for a 90-day
The Maintenance Network is a network of retail                   supply, and include up to three (3) 90-day refills,
pharmacies that contract with Medco to accept the                totaling one-year of medication. The original
co-payment amount for maintenance medication.                    prescription must be attached to a completed
Pharmacies in this network may also be an in-                    Medco Mail Order form and sent to the address
network retail pharmacy as described in the                      indicated on the form. Order forms and refills
Non-Maintenance Medication section. If a plan                    can be obtained by contacting Medco.

 Special Note Regarding Medications for Nursing                  co-payment for their medication. The request should
 Home/Extended Care Facility QCHP Patients                       be in the form of a letter, and must include the patient’s
 Due to the large amounts of medication generally                name, a list of all medications the patient is taking
 administered at nursing home and extended care                  and the dosage of each medication. The effective
 facilities, many of these types of facilities cannot            date of the exception is the receipt date of the request.
 maintain more than a 30-day supply of prescriptions             Requests must be submitted to the Group Insurance
 per patient.                                                    Division, Member Services Unit, 201 E. Madison, P.O.
                                                                 Box 19208, Springfield, Illinois 62794-9208.
 In order to avoid being charged a double-copayment
                                                                 Note: Since each request is based on a specific list of
 for a 30-day supply, the patient or person who is
                                                                 medications, any newly prescribed medication(s)
 responsible for the patient’s healthcare (such as a
                                                                 must be sent as another request.
 spouse, power of attorney or guardian) should submit
 a letter requesting an ‘exception’ to the double

                                                            17                             www.benefitschoice.il.gov
Prescription Drug Benefit
  Co-Pays and Deductibles
Formulary lists categorize drugs in three levels: generic, preferred brand and non-preferred brand. Each
level has a different co-payment amount. A plan year deductible applies to each plan participant covered
by the health plan.

                                               PRESCRIPTION PLAN
                                            QCHP         All Other Plans
     Generic                                                     $11                        $10
     Preferred (formulary) Brand                                 $26                        $24
     Non-Preferred Brand                                         $52                        $48
     Deductible                                                  $75                        $50

All plan participants are responsible for a prescription deductible. Plan participants enrolled in a managed
care plan have an annual prescription deductible of $50; plan participants enrolled in the Quality Care
Health Plan have an annual prescription deductible of $75. Annual prescription deductibles must be
satisfied before the prescription co-payments apply. However, if the cost of the prescription is less than
the plan’s co-payment, the plan participant will pay the cost of the prescription.

 Example I – Generic Drug Costs Less than the Deductible
                               Total Cost      Deductible      Deductible     Co-payment         Total
                                of Drug         Applied        Remaining                        Payment
 QCHP First Fill                  $55             $55             $20              $0             $55
 QCHP Next Fill                   $55             $20              $0              $11            $31
 Managed Care First Fill          $37             $37             $13              $0             $37
 Managed Care Next Fill           $37             $13              $0              $10            $23

 Example 2 – Generic Drug Costs More than the Deductible
                                Total Cost     Deductible      Deductible     Co-payment         Total
                                 of Drug        Applied        Remaining                        Payment
  QCHP First Fill                 $100            $75             $0               $11            $86
  QCHP Next Fill                  $100            $0              $0               $11            $11
  Managed Care First Fill         $100            $50             $0               $10            $60
  Managed Care Next Fill          $100             $0             $0               $10            $10

                                                        Vision Plan
                                                        Vision coverage is provided at no additional cost to
                                                        members enrolled in any of the State-sponsored health
                                                        plans. All members and enrolled dependents have the
                                                        same vision coverage regardless of the health plan
                                                        selected. Eye exams are covered once every 12 months
                                                        from the last date the exam benefit was used. All other
                                                        benefits are available once every 24 months from the
                                                        last date used. Co-payments are required.

 Service                          Network                      Out-of-Network**               Benefit Frequency
                                  Provider Benefit             Provider Benefit
 Eye Exam                         $10 co-payment               $30 allowance                  Once every 12 months
 Spectacle Lenses*                $10 co-payment               $50 allowance for single       Once every 24 months
 (single, bifocal and trifocal)                                vision lenses

                                                               $80 allowance for bifocal
                                                               and trifocal lenses
 Standard Frames                  $10 co-payment               $70 allowance                  Once every 24 months
                                  (up to $175 retail
                                  frame cost; member
                                  responsible for
                                  balance over $175)
 Contact Lenses                   $120 allowance               $120 allowance                 Once every 24 months
 (All contact lenses are in
 lieu of standard frames
 and spectacle lenses)

 * Spectacle Lenses: Plan participant pays any and all optional lens enhancement charges. Network providers may
   offer additional discounts on lens enhancements and multiple pair purchases.
** Out-of-network claims must be filed within one year from the date of service.

≈   EyeMed Vision Care: (866) 723-0512
    TDD/TTY: (800) 526-0844
    Website: www.eyemedvisioncare.com/stil

                                                          19                               www.benefitschoice.il.gov
                   Dental Options
All members and enrolled dependents have the same dental benefits
available regardless of the health plan selected. Participants may go
to any dental provider for services. During the Benefit Choice Period,
members have the option to drop dental coverage. The election to
drop coverage will remain in effect the entire plan year, without
exception. The Benefit Choice Period is also the only time members
may elect dental coverage if they previously dropped the coverage.

Dental Benefit                                            Child Orthodontia Benefit
The Quality Care Dental Plan (QCDP) reimburses            The child orthodontia benefit is available only to
only those services listed on the Dental Schedule         children who begin treatment prior to the age of
of Benefits, available on the Benefits website.           19. There is a maximum lifetime benefit for child
Listed services are reimbursed at a predetermined         orthodontia of $2,000. This maximum represents
maximum scheduled amount. Members are                     a $250 increase from FY10. Children currently
responsible for all charges over the scheduled            undergoing a course of orthodontia treatment are
amount and/or over the annual maximum benefit.            eligible for the additional $250 benefit after the
                                                          $125 plan year deductible has been met for FY11.
Each plan participant is subject to an annual plan        This lifetime maximum is subject to course of
deductible for all dental services, except those          treatment limitations (see 'Length of Orthodontia
listed in the Schedule of Benefits as ‘Diagnostic’        Treatment' chart below).
or ‘Preventive’. The annual plan deductible is
$125 per participant per plan year. Once the              Orthodontia Services
deductible has been met, the plan participant has
a maximum annual dental benefit of $2,500 for all          Annual Deductible                  $125
dental services.                                           Lifetime Maximum Benefit           $2,000
                                                           Plan Year Maximum Benefit*         $2,500
Preventive and Diagnostic Services

 Annual Deductible                     N/A                Length of Orthodontia Treatment
 Plan Year Maximum Benefit*            $2,500             The lifetime maximum benefit for child orthodontics
                                                          is based on the length of treatment. This lifetime
All Other Covered Dental Services                         maximum applies to each plan participant
                                                          regardless of the number of courses of treatment.
 Annual Deductible                     $125
                                                           Length of Treatment          Maximum Benefit
 Plan Year Maximum Benefit*            $2,500
                                                             0 - 36 Months                  $2,000
* Orthodontics + all other covered services                  0 - 18 Months                  $1,820
                                                             0 - 12 Months                  $1,040
Prosthodontic Limitations
(Prosthodontics include full dentures, partial
dentures, implants and crowns)
• Prosthodontics to replace missing teeth are
  covered only for teeth that are lost while the
  plan participant is covered by this plan.
• Multiple procedures are subject to limitations.

  Please refer to the Dental Schedule of Benefits                         CompBenefits: (800) 999-1669
  PRIOR to the completion of any procedure to                             TDD/TTY: (312) 829-1298
  clarify coverage limitations.                                           Website: www.compbenefits.com

Life Insurance Plan*
Basic Life insurance is provided at no cost to annuitants and
active employees. This term life coverage is provided in an
amount equal to the annual salary of active employees. The
Basic Life amount for annuitants under age 60 is equal to the
annual salary as of the last day of active State employment.
For annuitants age 60 or older, the Basic Life amount is $5,000.
The life insurance plan offers eligible members the option to
purchase additional life insurance to supplement the Basic Life
insurance provided by the State.

Optional Life                                              Child Life
Optional Life coverage is available to all members.        Child Life coverage is available in a lump sum
Annuitants under age 60 and active employees               amount of $10,000 for each child. The monthly
can elect coverage in an amount equal to 1-8               contribution for Child Life coverage applies to all
times their Basic Life amount; annuitants age 60           dependent children regardless of the number of
and older can elect 1-4 times their Basic Life             children enrolled. Eligible children include:
amount. Members enrolled with Optional Life
coverage should review the chart on page 4 to be             • Children age 18 and under
aware of rate variations among age groups. Rate              • Children in the Student or Student on Medical
changes due to age go into effect the first pay                Leave of Absence Categories
period following the member’s birthday.
                                                             • Children in the Handicapped Category
The maximum benefit allowed for Member
Optional Life plus Basic Life coverage is
$3,000,000.                                                Statement of Health
                                                           Adding/increasing member Optional Life, as well
Accidental Death &                                         as adding Spouse Life and/or Child Life coverage,
                                                           is subject to prior approval by the Life Insurance
  Dismemberment                                            Plan Administrator, Minnesota Life Insurance
                                                           Company. Members must complete and submit a
Accidental Death and Dismemberment (AD&D) is               Statement of Health form to Minnesota Life for
available to members in either (1) an amount               review.
equal to their Basic Life amount or (2) an amount
equal to their Optional Life coverage amount, up
to four times their Basic Life amount.

Spouse Life
Spouse Life coverage is available in a lump sum
amount of $10,000 for the spouse of active                 * Deferred Annuitants and Survivors have different
employees and annuitants under age 60. Spouse                life insurance benefits. Contact your retirement
Life coverage decreases to $5,000 for annuitants             system for details.
age 60 and older. A corresponding premium

                                                                               Minnesota Life: (888) 202-5525
                                                                               TDD/TTY: (800) 526-0844
                                                                               Website: www.lifebenefits.com

                                                      21                         www.benefitschoice.il.gov
  The Flexible Spending
Accounts (FSA) Program
Employee Benefit Only - Does NOT Apply to Annuitants
During the Benefit Choice Period, employees may enroll in a Flexible
Spending Accounts (FSA) Program with an effective date of July 1, 2010.
The great advantage is that you pay no federal taxes on your contributions.
For example, if you put in $1,000 and are in a 20% federal tax bracket, you
save $200 ($1,000 x 20% = $200) over the course of the plan year.
FSA plan elections do not automatically carry over each year. You must
complete a new FSA Enrollment Form each year to participate. The
minimum monthly amount for which an employee may enroll is $20; the maximum monthly
amount is $416.66 ($555.54 for university employees paid over 9 months). The first deduction
for an FSA enrollment will be taken on a pre-tax basis from the first paycheck issued in July.
Employees should carefully review their paycheck to verify the deduction was taken correctly.
If you do not see the deduction on your paycheck stub, please contact your payroll office

Medical Care Assistance Plan (MCAP)
What is it? The Medical Care Assistance Plan (MCAP)        New this year: Employees who enroll in MCAP
is a program that allows you to set aside money,           will automatically be issued the MyFBMC Visa®
before taxes, from your paycheck to pay for                card at no cost to use for their FY11 plan year
health-related expenses not covered by insurance.          medical expenses. Documentation is required to
If you, or someone in your family (i.e., spouse            substantiate certain expenses paid with the card;
and/or eligible dependents), goes to the doctor or         therefore, you should review your monthly statement
dentist, takes medication or wears glasses,                from the plan administrator, FBMC, carefully to
whether you have insurance or not, MCAP may                ensure you are aware of the documentation
save you money.                                            requirements.
How much should I contribute? Contributions
depend on household needs—think about how
many co-pays you will have for physician visits or
prescriptions. Will you pay a deductible? Perhaps
you expect a large dental, orthodontic (e.g.,
braces) or vision expense (e.g., LASIK surgery).
Examples of expenses you cannot claim:
• Cosmetic services, vitamins, supplements
• Insurance premiums
• Vision warranties and service contracts
• Over-the-counter medicines and drugs will not
  be eligible for reimbursement beginning
  January 1, 2011, without a prescription
You have until September 30, 2011, to submit
claims for expenses that were incurred from July
1, 2010, through September 15, 2011; otherwise,
any money left in your account will be forfeited.
      The Flexible Spending
        Accounts (FSA) Program
Dependent Care Assistance Plan (DCAP)
This is not a plan to cover your dependent’s                 How much should I contribute? Contributions
health-related expenses. This is a plan to pay               depend on household needs—think about how
primarily for child care expenses of dependent               much you spend on child care every year. Will
children 12 years and under.*                                you use day care or a private nanny? Perhaps
                                                             your child is going to nursery school or day camp
What is it? The Dependent Care Assistance Plan               this year.
(DCAP) is a program that allows you to set aside
money, before taxes, from your paycheck to pay               Examples of expenses you cannot claim:
primarily for child care expenses* of dependent
children 12 years and under. If you (and your                • Overnight camp
spouse, if married), work full time and pay for day          • Day care provided by another dependent
care, day camp or after-school programs, then
DCAP may save you money.                                     • Day care provided “off the books”

Please note that if you claim the dependent care             • Kindergarten tuition
tax credit, it will be reduced, dollar for dollar, by        • Private primary school tuition
the amount you contribute to DCAP. Also,
depending on your household income, it might be              • Before and after-school care expenses for
advantageous to claim child care expenses on your              dependents age 12 and older.
federal income tax return. You cannot claim the
expenses on your tax return and use DCAP. Please
ask your tax adviser which plan is best for you.             You have until September 30, 2011, to submit
                                                             claims for services incurred from July 1, 2010,
* In addition to child care, the Dependent Care              through June 30, 2011; otherwise, any money left
Assistance Plan can be used to pay for the                   in your account will be forfeited.
dependent care expenses for any individual living
with you that is physically or mentally unable to
care for themselves and is eligible to be claimed
as a dependent on your taxes.

                                                                             ≈    FBMC: (800) 342-8017
                                                                                  TDD/TTY: (800) 955-8771
                                                                                  Website: www.myFBMC.com

                                                        23                        www.benefitschoice.il.gov
          Commuter Savings
          Program (CSP)
Employee Benefit Only - Does NOT Apply to Annuitants
or University Employees
The Commuter Savings Program (CSP) is a qualified transportation benefit
that allows employees to pay for eligible transit and/or parking expenses
associated with their work commute through payroll deductions. These
deductions will be taken before any Federal, State, FICA or Medicare taxes, resulting in more money in
your pocket! The pre-tax limit for calendar year 2010 for both the transit and parking benefit is $230.00
per month. The CSP program is only available to employees who are paid through the Comptroller’s
Office. CSP benefits may be elected, changed or cancelled anytime.

Parking Benefit                                            Transit Benefit
What is it? The CSP parking benefit allows you to          What is it? The CSP transit benefit allows you to
pay for the parking costs associated with your work        pay mass transit costs associated with your work
with pre-tax dollars. You can choose to have the           commute with pre-tax dollars. To enroll, just go
payment for your parking expenses sent directly            online to www.myFBMC.com and register. After
to your parking provider, or you can choose to be          you register, click on ‘My CSP’ and follow the
reimbursed for your parking expenses.                      prompts.

How does paying the garage/lot directly work? If           How does it work? Once you are enrolled, you will
you choose to have your parking lot or garage              receive your monthly benefit from the vendor prior
paid directly, the vendor will mail the payment to         to the benefit month. Your agency will then take
your parking provider prior to the benefit month.          payroll deductions beginning with the first pay
Your agency will then take payroll deductions              period of the benefit month. The deadline to enroll
beginning the first pay period of the benefit              is the 10th of the month prior to the benefit month.
month. The deadline to enroll is the 10th of the           Example: Tom rides the METRA from Glen Ellyn
month prior to the benefit month.                          to Ogilvie Center each day. A monthly transit
                                                           pass for this commute is $116.10. Tom enrolled
Example: Trisha parks at Joe’s Parking Garage.             prior to July 10th for the August benefit month.
The monthly fee to park is $200. Trisha decides to         The vendor sent Tom's August transit pass to his
save some money pre-tax and enrolls in the CSP             home on July 23rd for him to use on or after
prior to the July 10th cut-off date for the August         August 1st. Since Tom is paid semi-monthly, his
benefit month. The vendor sends Trisha's August            agency will take the first payroll deduction of
parking fees to Joe’s Garage at the end of July.           $58.05 from the August 1-15 pay period.
Since Trisha is paid on a semi-monthly basis, her
agency will take the first payroll deduction of
$100.00 from the August 1-15 pay period.

How does the reimbursement option work?
Employees who park in a different lot each day or
who plug a meter on a street may want to be
reimbursed for their parking expenses. No
receipts are required. Simply log on to

www.myFBMC.com and click on ‘My CSP –                                           FBMC: (800) 342-8017
Reimburse Me’ and follow the prompts. Your                                      TDD/TTY: (800) 955-8771
reimbursement check will be sent directly to your                               Website: www.myFBMC.com
house, or you may sign up for direct deposit.
          Optional Programs
Employee Assistance Program                                 Smoking Cessation Program
Employee Benefit Only – Does not apply to Annuitants        Benefit applies to all Members
There are two separate programs that provide                Members and dependents are eligible to receive a
valuable resources for support and information              rebate up to $200 for completing an approved
during difficult times for active employees and             smoking cessation program, limited to one rebate
their dependents: the Employee Assistance                   per participant, per plan year. One-time procedures
Program (EAP) and the Personal Support Program              are not considered an approved program.

The Employee Assistance Program (EAP) is for                Long-Term Care (LTC)
active employees NOT represented by the collective
bargaining agreement between the State and                  Benefit applies to all Members
AFSCME Council 31. These employees must                     Members may choose an optional group long-term
contact the EAP administered by Magellan                    care insurance plan through Metropolitan Life
Behavioral Health.                                          Insurance Company (MetLife). Premiums for this
                                                            plan are paid entirely by the insured directly to
The Personal Support Program (PSP) is for
bargaining unit employees represented by
AFSCME Council 31 and covered under the master              Call MetLife toll-free at 800-GET-MET8
contract agreement between the State of Illinois            (800-438-6388) for an enrollment kit.
and AFSCME. These employees must access EAP
services through the AFSCME Personal Support
Program.                                                    Hospital Bill Audit Program
                                                            Program applies to only QCHP Members
Both programs are free, voluntary and provide               The Hospital Bill Audit Program applies to hospital
problem identification, counseling and referral             charges. Under the Program, a member or
services to employees and their covered dependents          dependent who discovers an error or overcharge
regardless of the health plan chosen. All calls             on a hospital bill and obtains a corrected bill, is
and counseling sessions are confidential, except            eligible for 50% of the resulting savings. There is
as required by law. No information will be                  no cap on the savings amount. Note: Related
disclosed unless written permission is received             non-hospital charges, such as radiologists and
from the employee. Management consultation                  surgeons, are not eligible charges under the
is available when an employee’s personal problems           program. The program only applies when QCHP
are causing a decline in work performance. See              is the primary payer.
the inside back cover for website and other
contact information.

Adoption Benefit Program
Employee Benefit Only – Does not apply to Annuitants
State employees working full time or part time
(50% or greater) may request reimbursement of
eligible adoption expenses. The adoption must be
final before reimbursement may be requested.
The request for reimbursement must be received
within one year from the end of the plan year in
which the adoption became final.

                                                       25                         www.benefitschoice.il.gov
           Opt Out and Annuitant Waiver
Opt Out                                                         Annuitant Waiver
In accordance with Public Act 92-0600, full-time                When both spouses are covered by the State
employees, retirees, annuitants and survivors may               Group Insurance Program
elect to Opt Out of the State Employees Health
Insurance Program if proof of other major medical               Public Act 93-553 changed the State Employees
insurance by an entity other than the Department of             Group Insurance Act to allow annuitants who
Central Management Services is provided. This                   were currently enrolled as a dependent of their
election will terminate health, dental, vision and              State-covered spouse to remain a dependent and
prescription coverage for the member and any                    waive coverage in their own right, thereby
dependents.                                                     decreasing the cost of coverage for an annuitant
                                                                with less than 20 years of service.
Members opting out of the Program continue to be
enrolled with Basic Life insurance coverage only and            New annuitants who are currently enrolled as a
may elect optional life coverage.                               dependent who wish to remain enrolled as a
                                                                dependent once becoming an annuitant must
If you opt out of the Program you will not be eligible          complete the ‘Waiving Annuitant Group Insurance
for the:                                                        Coverage Notification and Election Form’ which
    – Free influenza immunizations offered annually by          acknowledges they are waiving health, dental and
      the Department of Healthcare and Family Services          vision coverage as an annuitant. The annuitant’s
    – COBRA continuation of coverage                            spouse cannot carry Spouse Life on the annuitant;
    – Smoking Cessation Program                                 however, the annuitant will have Basic Life
                                                                coverage and may apply for additional Optional
However, if you are an employee, you will still be              Life coverage, if eligible.
eligible for the:
    – Flexible Spending Account (FSA) Program
    – Commuter Savings Program (CSP)
    – Paid maternity/paternity benefit
                                                                Re-enrolling in the
    – Employee Assistance Program
    – Long-Term Care Program
                                                                 Health Plan
    – Adoption Benefit Program                                  Individuals who opt out or waive under either
                                                                Public Act may re-enroll in the Program only during
                                                                Benefit Choice, or within 60 days of experiencing
                                                                an eligible qualifying change in status. Members
Opt Out With                                                    who re-enroll, and their dependents, are subject

 Financial Incentive
                                                                to possible health benefit limitations for pre-existing
                                                                conditions. A Certificate of Creditable Coverage
SERS Annuitants not eligible for Medicare                       from the previous insurance carrier must be
                                                                provided to reduce the pre-existing conditions
In accordance with Public Act 94-0109, members not              waiting period.
eligible for Medicare receiving a retirement annuity
from the State Employees’ Retirement System (SERS)              Any outstanding premiums must be paid before
who are enrolled in the State Employees Health                  you will be allowed to re-enroll. Note: Survivors
Insurance Program and have other comprehensive                  and annuitants are not eligible to re-enroll if
medical coverage may elect to OPT OUT of the Health             previously terminated for non-payment of premium.
Insurance Program and receive a financial incentive
of $150 per month. Opting out includes health, vision,
dental and prescription coverage for the annuitant and
any dependents. Make sure to mark the 'Opt Out with
Financial Incentive' box on the Benefit Choice Election
Form if you are interested in this option. The Insurance
Section of SERS will send you additional forms to
complete that are required for this election.

                             FY2011 BENEFIT CHOICE ELECTION FORM
                                                             (Instruction Sheet on Back)
                                           Enrollment Period: May 1 – May 31, 2010
                                           Complete This Form Only If Changing Your Benefits

  SECTION A: MEMBER INFORMATION (required)                                                            SSN:             —            —
                  Last Name                            First Name                   Phone Numbers
                                                                                    Home:                             Work:

  SECTION B: OPT OUT/WAIVE or OPT IN (applies to your and your dependents' health, dental, vision and prescription coverage)
                                     See instructions on the back for additional documentation requirements
      Opt Out/Waive Coverage if currently enrolled in the Program                         Opt Out with Financial Incentive – only SERS Annuitants
                                                                                            who are not eligible for Medicare can elect this option
      Opt In or Elect Coverage if not currently enrolled

  SECTION C: HEALTH PLAN ELECTIONS (this election applies to your and your dependents' health coverage)
  Health Plan Election *                                       If you selected Managed Care Plan, you must complete the information
                                                               below. To find the provider identifier, go to the health plan’s website.
  Elect One:
                                                               See the instructions on back for more information.
  Quality Care Health Plan (QCHP)                 
                                                                 PCP/Provider Identifier _______________________ (6 - 10 characters)
              ~ Or ~
                                                               Carrier Code     ________ (2 characters – see map)
  Managed Care Plan (HMO or OAP)                  
                                                               Carrier/Plan Name         _________________________________________
  * If you have another health insurance plan, including Medicare, you must give a copy of your and/or your dependents’ other insurance card to your
    GIR. The copy must include the front and back of the card.

  SECTION D: DENTAL PLAN OPTION (complete ONLY IF CHANGING your current dental coverage election)
  Dental Plan Option – If you elect not to participate in the Dental plan, your Dental coverage (and any dependent dental coverage) will be
  terminated (health, vision and prescription coverage will remain active)
   I am currently enrolled in the dental plan and would like to             I am not currently enrolled in the dental plan and would like to
     drop the dental coverage                                                  elect the dental coverage

  SECTION E: MEMBER OPTIONAL LIFE INSURANCE (complete ONLY IF CHANGING your life coverage elections)
    OPTIONAL                 BASIC LIFE ONLY (free – equal to salary)                         AD&D (Accidental Death & Dismemberment)
      LIFE ¹                  BASIC + OPTIONAL (select increment below)             NO AD&D      BASIC AD&D only (Equal to Salary)
      1 x Salary            3 x Salary       5 x Salary       7 x Salary         AD&D COMBINED* (Basic Life + Optional Life)
                                                                                    * AD&D COMBINED maximum is Basic + 4 times Salary
      2 x Salary            4 x Salary       6 x Salary       8 x Salary
       Annuitants age 60 and over are not eligible for 5 – 8 times Salary

  SECTION F: DEPENDENT INFORMATION ² (will have the same health, vision, prescription and dental coverage as the member)
      HEALTH             LIFE ¹                                                                         Birth                        Sex      Provider
   A (Add) / D (Drop) / Change (C)                Name                               SSN                          Relationship ³
                                                                                                        Date                         (M/F)    Identifier
   A     D        C       A      D

  Note: ¹ Statement of Health form required when adding or increasing Optional Life or adding Spouse or Child Life. Form available online.
        ² Documentation required to add dependents – see specific documentation requirements on the back.
        ³ Relationship must be spouse, son, daughter, stepchild, adopted child, adjudicated child, legal guardianship, sponsored or veteran adult child.

  I authorize premiums as established annually to be deducted from my pay for those plans I have selected. I understand that if my paycheck is
  insufficient or if I am not on payroll, I will be direct billed. I agree to abide by all Group Insurance Program rules. I agree to furnish additional
  information requested for enrollment or administration of the plan I have elected. I understand it is my responsibility to review my paycheck and verify
  the amounts of the insurance deductions are accurate and that if my deductions are not correct I must immediately contact my GIR. Falsification of
  the information contained on this form may result in discipline up to and including discharge.

  MEMBER SIGNATURE: _______________________________________________                                          DATE: ___________________________
  GIR/GIP SIGNATURE: ________________________________________________                                        DATE: ___________________________

                      Give completed form to your GIR in your Benefits Office by May 31, 2010
CMS-350 IL401-1630 (03/31/10)                                                  27
                                          BENEFIT CHOICE ELECTION FORM
                                               INSTRUCTION SHEET
        If you are not changing your current coverage elections DO NOT complete this Benefit Choice Election Form

SECTION A – MEMBER INFORMATION (Complete all fields)

SECTION B – OPT OUT/WAIVE or OPT INTO Health, Dental, Vision and Prescription Coverage
Opting out or waiving coverage will discontinue all health, dental, vision and prescription coverage; Opting in will establish health,
dental, vision and prescription coverage; however you may elect to waive the dental coverage at the time you opt into the health,
vision and prescription coverage. Whether you opt out, waive or opt in, your life coverage elections will remain the same.
     • Full-time employees, annuitants and survivors may opt out of the coverage by submitting a completed Opt Out Election
          Certificate along with proof of other comprehensive health coverage (other coverage cannot be provided by Central
          Management Services).
     • Part-time employees, annuitants and survivors required to pay a percentage of the State’s portion of the premium
          may elect to waive the coverage without proof of other coverage.
     • Non-Medicare SERS annuitants may be eligible to receive a $150.00 financial incentive when they opt out of the State’s
          coverage and provide proof of other comprehensive health coverage (other coverage cannot be provided by Central
          Management Services). Once you elect this option to opt out you will be mailed a packet by SERS. The packet will include
          additional required forms. Note: This option is NOT available for annuitants of SURS, TRS, GARS or JARS.
     • The completed forms and documentation must be submitted to your Group Insurance Representative (GIR).
If you wish to change your health plan you must check either the Quality Care Health Plan (QCHP) or the Managed Care Plan box.
If electing/changing managed care plans, you must enter the managed care plan’s carrier code (see map for carrier codes), the
plan’s name and the provider identifier. The provider identifier is associated with a specific physician and is referenced as either the
PCP code (at least 6 characters) or NPI code (10 characters). Provider identifiers are located in the managed care plan’s online
directory, available on the plan's website (see inside front cover of this booklet for website addresses).

Do not complete this section if you only want to change your Primary Care Physician (PCP) – you must contact your managed care
plan directly in order to make this change.

Your election decision will apply to both your and your dependents’ dental coverage.
    • If you are currently enrolled in the dental plan and wish to drop the coverage, check the appropriate box. This election will
         remain in effect until you re-elect the dental coverage, which is only allowed during a future Benefit Choice election period.
    •     If you are currently not enrolled in the dental plan and wish to elect the coverage, check the appropriate box. The Benefit
          Choice Period is the only time you can elect dental coverage if you previously dropped the coverage. Members must be
          enrolled in the health plan in order to elect this option.

Complete this section to add/drop/increase or decrease Member Optional Life or AD&D coverage. Note: Life coverage is subject to a
$3,000,000 maximum (Basic Life + Optional Life). Adding and/or increasing Optional Life requires a signed Statement of Health
application* for the member. Annuitants age 60 and older are not eligible for 5 – 8 times of Optional Life coverage.

Complete this section if you are adding or dropping (1) dependent health/dental/vision/prescription coverage or (2) Spouse/Child Life
coverage. Adding Spouse Life and/or Child Life requires a signed Statement of Health application* for that dependent. If you are
adding a dependent for the first time, you must provide your GIR/P with the appropriate documentation as indicated below:
 Spouse                                    Marriage certificate.
 Natural Child through Age 18              Birth certificate.
 Stepchild through Age 18                  Birth certificate indicating your spouse is the child’s parent, marriage certificate and proof
                                           the child resides with you at least 50% of the time.
 Adopted Child through Age 18              Adoption certificate stamped by the circuit clerk.
 Adjudicated Child/Legal Guardianship      Court documentation signed by a judge.
 through Age 18
 Student and Student Medical LOA            Birth certificate, Eligibility Certification Statement (CMS-138)* and documentation as
 Sponsored Adult Child                      indicated on the ‘Documentation Requirements’ page of the Eligibility Certification
 Veteran Adult Child (IRS/non-IRS)          Statement.
 Other (organ transplant recipient)
 * The Eligibility Certification Statement (CMS-138) and the Statement of Health application are available on the Benefits Website
   at www.benefitschoice.il.gov.

SIGNATURE: In order for your elections to be effective July 1, 2010, you must sign and date the Benefit Choice Election Form and
submit it to your agency GIR by May 31, 2010. Dependent documentation must be submitted to your GIR within 10 days of the end
of the Benefit Choice Period. If documentation is not provided within the 10-day period, your dependent(s) will not be added.

Plan Administrators
Who to call for information
     Plan                        Contact For:                  Administrator’s                   Customer Service
   Component                                                  Name and Address                  Contact Information
                                  Medical service                    CIGNA
  Quality Care               information, network                Group Number                       (800) 962-0051
Health Plan (QCHP)          providers, claim forms,                 3181456                           (nationwide)
  Medical Plan                    ID cards, claim              CIGNA HealthCare               (800) 526-0844 (TDD/TTY)
 Administrator                filing/resolution and              P.O. Box 5200                http://provider.healthcare.
                              predetermination of                 Scranton, PA                    cigna.com/soi.html
                                      benefits                    18505-5200
      QCHP                    Notification prior to              Intracorp, Inc.                    (800) 962-0051
 Notification and              hospital services                                                      (nationwide)
  Medical Case                                                                                (800) 526-0844 (TDD/TTY)
  Management                   Non-compliance                                                 http://provider.healthcare.
  Administrator             penalty of $800 applies                                               cigna.com/soi.html
  Prescription                  Information on                     Medco
   Drug Plan                   prescription drug               Group Number:                        (800) 899-2587
  Administrator              coverage, pharmacy              1400SD3, 1400SBS,                        (nationwide)
 QCHP (1400SD3)              network, mail order,            1400SCE, 1400SCf
                              specialty pharmacy,              Paper Claims:
    Health Alliance              ID cards and               Medco Health Solutions            (800) 759-1089 (TDD/TTY)
 Illinois (1400SBS)               claim filing                 P.O. Box 14711
                                                             Lexington, KY 40512
Humana-Winnebago                                                                                   www.medco.com
   (1400SCE)                                               Mail Order Prescriptions:
  HealthLink OAP                                                P.O. Box 30493
    (1400SCf)                                               Tampa, fL 33630-3493

                                   Notification,             Magellan Behavioral
                              authorization, claim                  Health                         (800) 513-2611
 QCHP Behavioral               forms and claim              Group Number 3181456                     (nationwide)
     Health                     filing/resolution               P.O. Box 2216                 (800) 526-0844 (TDD/TTY)
  Administrator                  for Behavioral              Maryland Heights, MO             www.MagellanHealth.com
                                Health Services                     63043

    Employee                Confidential assistance          Magellan Behavioral                   (866) 659-3848
    Assistance                and assessment                          Health                         (nationwide)
  Program (EAP)                    services                     -for Non-AfSCME               (800) 526-0844 (TDD/TTY)
                                                             represented employees-           www.MagellanHealth.com

 Personal Support          Confidential assessment           AFSCME Council 31                     (800) 647-8776
     Program               and assistance services                -for AfSCME                        (statewide)
  (PSP – AFSCME                                              represented employees-           (800) 526-0844 (TDD/TTY)
       EAP)                                                                                      www.afscme31.org

The State of Illinois intends that the terms of this plan are legally enforceable and that the plan is maintained for the
exclusive benefit of Members. The State reserves the right to change any of the benefits and contributions described in this
Benefit Choice Options Booklet. This Booklet is intended to supplement the Benefits Handbook. If there is a discrepancy
between the Benefit Choice Options Booklet, the Benefits Handbook and state or federal law, the law will control.

Illinois Department of Central Management Services
                 Bureau of Benefits
                    PO Box 19208
              Springfield, IL 62794-9208

   Printed by the authority of the State of Illinois
             Printed on recycled paper

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